1. The Field of the Invention
This invention, in one configuration, relates generally to the treatment of coronary disease, and more particularly, to the localized delivery of beneficial agents. In one configuration, the invention may be used for the treatment of vulnerable plaque.
2. The Relevant Technology
Coronary heart disease is generally thought to be caused by the narrowing of coronary arteries by atherosclerosis, the buildup of fatty deposits in the lining of the arteries. The process that may lead to atherosclerosis begins with the accumulation of excess fats and cholesterol in the blood. These substances infiltrate the lining of arteries, gradually increasing in size to form deposits commonly referred to as plaque or atherosclerotic occlusions. Plaques may narrow the arterial lumen and impede blood flow. Blood cells may collect around the plaque, eventually creating a blood clot that may block the artery completely.
The phenomenon of “vulnerable plaque” has created new challenges in recent years for the treatment of heart disease. Unlike occlusive plaques that impede blood flow, vulnerable plaque develops within the arterial walls, but it often does so without substantially narrowing the arterial lumen. Therefore, early symptoms of disease may not be present. As such, conventional methods for detecting heart disease, such as an angiogram, may not detect vulnerable plaque growth in the arterial wall. After death, an autopsy may reveal the plaque congested in arterial walls that could not have been seen otherwise with currently available medical technology.
The intrinsic histological features that may characterize a vulnerable plaque may include increased lipid content, increased macrophage, foam cell and T lymphocyte content, and reduced collagen and smooth muscle cell (SMC) content. This fibroatheroma type of vulnerable plaque is often referred to as “soft”, having a large lipid pool of lipoproteins surrounded by a fibrous cap. The fibrous cap contains mostly collagen, whose reduced concentration combined with macrophage derived enzyme degradations can cause the fibrous cap of these lesions to rupture under unpredictable circumstances. When ruptured, the lipid core contents, thought to include tissue factor, contact the arterial bloodstream, causing a blood clot to form that can completely block the artery resulting in an acute coronary syndrome (ACS) event. This type of atherosclerosis is coined “vulnerable” because of the unpredictable tendency of the plaque to rupture. It is thought that hemodynamic and cardiac forces, which yield circumferential stress, shear stress, and flexion stress, may cause disruption of a fibroatheroma type of vulnerable plaque. These forces may rise as the result of simple movements, such as getting out of bed in the morning, in addition to in vivo forces related to blood flow and the beating of the heart. It is thought that plaque vulnerability in fibroatheroma types is determined primarily by factors which may include: (1) size and consistency of the lipid core; (2) thickness of the fibrous cap covering the lipid core; and (3) inflammation and repair within the fibrous cap.
FIG. 1A illustrates a partial cross section of an artery having a narrowed arterial lumen caused by the presence of occlusive atherosclerosis. Plaque may accumulate to impede and reduce blood flow through the arterial lumen and thus may often cause symptoms (e.g., angina pectoris). The arrows indicate the direction of blood flow through the arterial lumen. FIG. 1B illustrates an occlusive atherosclerosis within an arterial lumen resulting in significant reduction in lumen patency. This type of atherosclerosis can easily be detected through current diagnostic methods such as an angiogram. FIG. 1B also illustrates, downstream from the occlusive atherosclerosis, a fibroatheroma type of vulnerable plaque. The vulnerable plaque, with a lipid core, develops mostly within the arterial wall with minimal occlusive effects such that it is not easily detected by current diagnostic methods. This is partially due to a phenomenon known as “positive remodeling”, which allows the vessel to respond to the presence of disease. The fibroatheroma vulnerable plaque has grown into the positively remodeled arterial wall so that vessel occlusion has not been manifested. A fibrous cap surrounds the vulnerable plaque.
FIGS. 2A-2C illustrate a cross-sectional view of the accumulation of vulnerable plaque in the arterial wall. FIG. 2A illustrates an arterial wall that is not affected by atherosclerosis. The normal arterial wall consists of an intima layer, a media layer, and an adventitia layer. The intima is in direct contact with the blood flow within the arterial lumen. The intima consists mainly of a monolayer of endothelial cells. The media consists mostly of smooth muscle cells and extracellular matrix proteins. The outermost layer of the arterial wall, the adventitia, is primarily collagenous and contains nerves, blood vessels, and lymph vessels. FIG. 2B illustrates the large presence of a fibroatheroma type vulnerable plaque surrounded by a fibrous cap within the arterial wall. The vulnerable plaque consists mainly of a large lipid core. The fibrous cap layer shields the lumen of the artery from the thrombogenic components in the core. FIG. 2C illustrates an occlusive thrombosis event resulting from the rupturing of the fibrous cap. Thrombogenic components in the vulnerable plaque contact luminal blood and cause the thrombotic event.
Autopsy studies and other evidence strongly suggest that the presence of a current acute coronary syndrome (ACS) event and/or existing thrombus at certain plaque sites may correlate to predicting a future ACS event in a given patient. The latter indicates the likelihood of a prior thrombotic event (e.g., fibroatheroma rupture) after which the plaque was able to heal itself, or complete occlusion of the vessel was somehow prevented. Autopsy studies also indicate that it is reasonable to expect that at least one vulnerable plaque could exist in the majority of catheterization laboratory patients being treated for arterial blockage from visible occlusive atherosclerosis. Many of the patients at highest risk, therefore, for future ACS events may already be receiving interventional treatment, even though current methods to diagnose occlusive plaques (i.e., non-vulnerable type plaque) may not be effective for enabling therapy for vulnerable plaque. Furthermore, treating both the occlusive plaques and the vulnerable plaque in one procedure might be beneficial and desirable compared to separate treatments. This would provide a greater convenience to the patient and for the physician.
One method for the treatment or prevention of disease that has been suggested is the extravascular administration of anti-microtubule agents such as paclitaxel. This method has specifically focused on the administration of the agents either through the chest wall or external surface of the pericardial sac, such as in open chest procedures. The pericardial sac is the anatomical space between the two layers of the pericardium. Additionally, it has been suggested that the pericardial sac can be accessed through the atrial or ventricular walls of the heart using catheter guided needles. The procedures described have a major disadvantage in light of the previous discussion since they do not readily lend themselves to treating occlusive plaques and vulnerable plaque disease in the same procedure. Additionally, the techniques used to administer the agents may be significantly different from common interventional cardiology techniques such as PTCA, therefore requiring significant physician training. Finally, the techniques may be time consuming, making them less desirable options for treating coronary disease.
Another method of treating coronary disease through the delivery of a therapeutic substance includes the use of a catheter-based device incorporating a needle whereby the substance can be delivered to the treatment site, such as a vessel wall or lesion therein. While this disclosure may be more similar to conventional interventional techniques than the method previously discussed, it may have the disadvantage of only providing localized delivery of the substance within the heart. In the case of vulnerable plaque, the disease may be profuse and difficult to identify throughout the entire coronary vascular tree. Therefore, the localized nature of this method may result in a higher potential of ineffective treatment.